Diseases of children: A Manual...

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Preface

In preparing this manual for publication the author has had especially in view the requirements of the beginner in the study of pediatrics. His design has been to cover the subject fully yet in a concise form, dealing more largely wth the physiology of infancy and with artificial feeding than with the pathological states found in childhood. Such diseases as in no wise differ from the same conditions as seen in adult life have been but briefly described. For more extended information on such subjects, or on those coming under the head of the so-called " specialties," the student is referred to more extended treatises.

No attempt at originality is professed, and acknowledgment is hereby made of free reference to the standard text-books on the subject of pediatrics, the treatise of Holt having been most frequently consulted.

The aim has been to present the subject in a systematic, orderly form, and in as few words as possible, both of which conduce to ease of study and reference.

GEORGE M. TUTTLE.

St. LouiSy Mo.

Chapter I. The Infant At Birth

RESPIRATION.

How established : In beginning extra-uterine life breathing is a child's first new function. Previously its lungs have been impervious to air and to other than nutritive blood. Now the placental circulation is stopped and the blood must pass into the lungs to be oxygenated. By the reflex stimuli of comparatively cold air on the skin and of venous blood feeding the respiratory center in the medulla respiration is begun, usually with a cry. Each breath is deeper than the preceding one, until the whole lung gradually passes from a state of physiological atelectasis to complete expansion.

Extenud signs: This change can be beautifully watched by observing the chest-wall, which, being very elastic and yielding, will stay depressed, in inspiration, over unexpanded lung, while those parts over expanded lung will rise and fall with the motions of the chest in breathing. To be satisfied that respiration is fully established, one should see that no part of the chest-wall sinks during inspiration.

Rate : The child should now breathe about forty-five times to the minute, but the respiratory rhythm is likely to be irregular.

As aids to effecting natural respiration, slapping the buttocks, blowing on the skin, or alternate applications of hot and cold water, are usually all that are necessary.

OIROnLATION.

In this another marked change occurs. The umbilical vein and ductus venosus, leading from the umbilicus to the in- 1— D. c. 17

18 THE INFANT AT BIRTH.

ferior vena cava, are closed, dwindling to a fibrous cord, the round hepatic ligament, in two to five days. The Eustachian valve, which guided the blood from the right auricle to the left auricle, disappears at once; the foramen ovale, through which the blood j)asses from the right auricle to the left auricle, closes in ten days, by a fold of endocardium growing over it from below; the ductus arteriosus, which carried the blood from the pulmonary artery to the descending aorta, becomes an impervious cord in four to ten days; and the umbilical arteries, which carried the blood from the internal iliacs to the navel, become the anterior vesical ligaments above, and remain as the superior vesical arteries below.

The pulse at birth varies from 140 to 120 per minute, and is frequently irregular. The higher rate is found in girls and small infants ; the lower, in boys and large infants.

TEMPERATURE.

At birth the temperature is about 99° F. It may sink rapidly directly after birth ; but in a healthy child it soon regains normal. The new-born infant is naturally very sensitive to cold, having lived so long in a temperature of 98° F., and great care must be taken to prevent chilling.

SKIN.

Vemix caseosa : The child at birth is covered, to a greater or less degree, with a slippery white substance, the vemix caseosa, a mixture of epithelium, down, and secretion from the sebaceous glands.

Lanugo : In addition to the vernix caseosa, the skin shows an abundant growth of very fine downy hairs, the lanugo, which soon disappears.

Desquamation: Shortly after birth the skin is frequently very red, and later marked desquamation may occur.

LENGTH.

The average length is about twenty inches. Below eighteen inches is evidence of prematurity.

WEIGHT— INTESTINES, 19

WEIGHT.

Boys average seven and a half pounds ; girls, about seven pounds. Below five and a half pounds shows a very low vitality and suggests prematurity.

HEAD.

Measurements and fontanelles: The head measures about thirteen inches in circumference in the occipito-frontal line. The anterior fonlanelle, at the junction of the coronal and the sagittal sutures, is open one and a half by one-half inch. The posterior fonianeUe, formed by the sagittal and lambdoid sutures, is also plainly to be felt.

Caput succedaneum : The head is apt to be much misshapen from pressure during its passage through the pelvis, and on one place is a thick boggy swelling, the caput auccedaneumy formed by serous infiltration into the tissues of the scalp over the part presenting in the birth-canal, and hence escaping pressure. The caput disappears in a few days, and the snape of the head rights itself in a few weeks, both without assistance.

THORAX.

Measurements : The average circumference of the chest at the nipple-line is thirteen inches, the same as that of the head, the antero-posterior and transverse diameters being about equal. With the addition of the shoulders, we have a decidedly larger sized body than the head, a point of importance in connection with the birth of the shoulders over the perineum.

ABDOMEN.

Here the average circumference is about fourteen inches.

INTESTINES.

Meconium: At birth the intestines contain a very dark green, pasty substance called meconium, made up of bile, epithelium, intestinal mucus, and lanugo. This is voided in considerable quantities directly after, and sometimes during

20 THE INFANT AT BIRTH.

birth, and, under the influence of the colostrum, for the next four days. It is found to be absolutely sterile and free from bacterial life.

EIDNE7S.

Urine : Constantly after birth the bladder empties itself of a small quantity of limpid urine of low specific gnivity.

XJiic acid and urates : In the kidneys themselves there are deposits of uric acid and urates, the so-called infarctify crystals of which pass down the ureters and are found as purplish stains on the dia[)ers. During this passage they may cause sharp pains. This is a frequent cause of crying in infancy, and shows the lack of sufficient water in the system.

UMBILIGAL CORD.

Pulsation : The umbilical cord will be found to be strongly

Eulsating at birth, and it is best to wait for this to stop efore ligating. An exception to this rule is made in congestive asphyxia, where the withdrawal of some blood from the child is desirable. It has been found that when the cord is not tied until after pulsation is stop}>ed the infant gains on an average of three ounces of blood, and its initial loss of weight is lessened.

Ligation: The cord should be tied tw^o inches from the navel, very tight, with narrow aseptic bobbin, and cut beyond with aseptic scissors. Before leaving, the stump should ])e examined, as it is quite common to find it bleeding a little. Dress the stump with dry sterilized gauze or cotton, dusting with powdered bismuth. Sometime within a week the cord should drop off by a process of dry gangrene, leaving a healthy ulcer at the base.

BATHING.

After tying and cutting the cord the infant should be greased thoroughly with vaseline, and laid aside in a warmed woollen blanket, with a soft towel next the skin, until the mother is entirely attended to.

EYES— CLOTHING, 21

Then the baby should have a general bath, in a warm room, before an open fire, if possible, in water of a temperature of 100° F. Castile soap, a soft sponge, and a soft towel should be the adjuvants. After drying, all the flexures and creases in the skin should be dusted with talcum, or some similar dry powder.

ETES.

Infection : There is always danger of some form of infection to the conjunctivae from the uterine and vaginal secretions. It is therefore wise to follow the prophylactic treatment introduced by Cr6d^, of first washing the eyes with clean water, or saturated boric acid solution, and then instilling a couple of drops of a 2 per cent, silver nitrate solution into each eye, being sure that the lids are open so that the silver reaches the whole conjunctiva, bulbar and tarsal. The baby should be kept in a darkened room the first few days.

Strabismus : It is well to remember that co-ordinate movements of the eyeballs are imperfectly performed in infancy and hence strabismus is frequently present.

MOUTH.

The month should be freed from mucus, liquor amnii, or whatever may have gotten into it during birth, by sweeping the finger, covered with a piece of soft dry gauze, carefully and gently over the whole cavity, going well back into the pharynx.

EXAMINATION FOB ABNORMALITIES.

This should next be made, with special attention to the skin, nwuih, head, spine, hands, fed, genitals, and aniLs,

CLOTHING.

This should be light, warm, unirritating, and allow free movement of the body and limbs. \ broad abdominal flannel band should l)e worn the first four months. The other essentials are a woollen shirt, a flannel petticoat, a

22 THE INFANT AT BIRTH,

diaper, and a dress. For night, the dress is exchanged for a night-gown. Safety-pins only should be used in fastening the clothing.

POOD.

Golostnun: Nature prepares no real food for the first three or four days, but during this time the breasts of the mother secrete colostrum, a thin bluish fluid, showing under the microscope the presence of large corpuscles in addition to a small number of the usual fat-globules. This colostrum is laxative in its action. Eight or ten hours after birth the baby should be put to the breast, and, after this, four times daily until the milk comes. This accustoms the baby to sucking, reflexly stimulates the uterus to contract, and hastens the discharge of the meconium.

If there really seems to be need of any food, as in weakly infants, a 5 per cent, migar solution is the best form until lactation begins. Excessive crying, as if from hunger, in a healthy baby can usually be stopped by simply giving boiled water.

SLEEP.

The child should sleep almost continuously during the first few days. From the very start, training in good sleeping^ habits should begin, the baby being taken up i^nly to wash and to nurse, and being taught to go to sleep when laid down, and allowed to sleep in a crib by itself. No walking nor rocking it, nor other bad habits, should be permitted.

PBEMATUBE AND DELICATE INFANTS.

Viability : Probably no child of less than twenty-seven or twenty-eight weeks of intra-uterine life can survive. Each week after this increases its chances considerably. In these babies the vitality is very low, the organs of dig(?stion, circulation, and respiration are very imperfectly developed, and, above all things, the heat-producing function is very slight.

In treatment the two most difficult problems are to maintain the animal heat, and properly to nourish them. They should not be clothed, but rather wrapped up in cotton and

PREMATURE AND DELICATE INFANTS. 23

then in blankets, and surrounded constantly by hot bottles, and kept in as nearly as possible a uniform high temperature. This can be best accomplished in an incubatory if one can be obtained. The skin should be thoroughly greased with sweet oil, and no bathing should be allowed.

Breast-milk from the mother, or a wet-nurse, is the very best foody and should be given in small quantities, from one-half to three-quarters of an ounce, every one and a half hours. This may be given by a large medicine-dropper, or by gavage, without removing the baby from its " nest. If breast-milk cannot be obtained, a carefully modified diluted cows' milk is the next best food.

Chapter II. Normal Development Of The Infant

WEIGHT.

During the first year the child should be weighed every week, and during the second year every other week. The gain or loss in weight from one weighing to another is the very best indication we have of the general welfare of the child. Frequently the first signal of beginning trouble is the absence of the regular weekly gain, or the presence of a slight loss.

Physiological loss : During the first three days of life there is a so-called physiological loss in weight, averaging about ten ounces. This is due to loss of urine, meconium, and vernix caseosa, and the lack of food the first few days. With the advent of milk in the mother's breasts the normal gain begins, and, by about ten days, the birth-weight should be regained.

At six months the birth-weight is about doubled, and at the end of a year about trebled. During the first six months the gain should average four to eight ounces per week ; and from two to four ounces during the second six months. From four to six pounds per year is about an average gain for the next ten years.

Sickness of any kind, and particularly digestive disturbances, stop the normal gain, and usually substitute a loss. Even the physiological process of dentition is accompanied by a diminished weekly gain.

HEIGHT.

During the first year the growth is about eight inches, an average of two-thirds of an inch per month, the increase being somewhat greater during the first quarter. During the second year the growth h about four inches, and during

HEAD— MUSCULAR ACTS. 25

the next ten years it averages about two inches per year. This growth, in infancy, takes place more rapidly in the extremities than in the trunk, although at birth the trunk was relatively longer than the limbs.

HEAD.

During the first year the occipito-frontal circiiinferenee of the head nhould increase about four inches, and about one inch more during the second year. A gain of an inch and a half more should take place by the fifth year, at which time the head attains its adult size.

The cranial sntnres ossify by the sixth month, the posterior fontanelle closing by the second month, but the anterior not till the eighteenth month, having increased some in size during the first nine months. Early closing fontanelles and sutures suggest premature ossification, or cerebral defects; while fontanelles and sutures remaining open over time are suggestive of ridkets or hydrocephalus.

THORAX.

The thorax grows more transversely than from before backward, keeping j)ace with the growth of the head, and not until the thii9 year is it distinctly larger than the head. A chest of a three years' child not larger than its head points to extreme delicacy.

ABDOMEN.

The abdomen at birth is larger than both head and chest ; at two years it should be about the same size, and afterward the smallest of the three.

MUSGULAB ACTS.

Voluntary, but inco-ordinate muscular movements are made about the fourth month. The head is held erect about the same time. The child sits erect about the seventh month. The first attempts at walking: are made about the twelfth to the fifteenth month, some children learning to creep three or four months earlier.

26 NORMAL DEVELOPMENT OF THE INFANT,

PULSE.

The force and rhythm in infancy arc the important factors rather than the rate. During the first year the frequency varies from 110 to 140, reaching 100 by the end of the second year. By the eighth year the adult rate is present. The rate is markedly influenced by very trivial causes, such as crying, struggling, or excitement, making its value uuimportant. It is helpful to remember that the pulse can be easily counted in the anterior fontanelle.

BESPIBATION.

Bespiration is chiefly abdominal^ and the rapidity very variable. During sleep it averages considerably less than during wakefulness. The rate in the first montlis is thirty-five to forty; during the second year it falls to twenty-eight ; during the third, to twenty-five ; and by puberty it reaches the adult rate, eighteen to the minute.

In health, the rhythm — inspiration, expiration, pause — is unchanged. The ratio between pulse and respiration is about three and a half to one.

TEMPEBATUBE.

After the more or less marked fall succeeding birth the temperature immediately assumes the adult range, the main point to be kept in mind l)eing the extreme fluctuations under slight causes, the heat-centres being very un.sta])le. In the chronic wasting diseases a subnormal tem|)erature is quite common.

DENTITION.

At birth the teeth are encjlosed in the dental sacs in the alveoli of the jaws, and their growth is upward by calciiication of their roots, this growth beginning at birth.

The milk or decidnous teeth are twenty in number, and are cut in the following order, although quite wide variations are frequent :

1. Two lower central incisors, at six to nine months ; 2^

URINE. 27

Four upper incisors^ at eight to twelve months; 3. Two lower lateral incisors and four anterior molars, at twelve to fifteen months ; 4. Four canines^ at twelve to fifteen months ; 5. Four posterior molars, at twenty-four to thirty months.

Early teething usually means early ossification of the cranial bones ; and late teething usually means rickets, or other form of malnutrition.

In a healthy child dentition is usually not accompanied by any constitutional disturbance, the tooth very gradually forcing its way through the overlying gum by a process of pressure-absorption, first showing its presence as a lump under the reddened mucous membrane, this growing whiter as the tooth nears the surface.

If any symptoms are present, they are only restlessness, fretfulness, disturbed sleep, salivation, a disposition to put objects into the mouth, and possibly a little fever.

In previously unhealthy children more serious symptoms may coincide with dentition, such as vomiting, diarrhoea, fever, earache, eczematous eruptions, and possibly convulsions; but there is always the question whether the unhealthy condition as a predisposing factor is not more of a cause of the symptoms than the teething. The more carefully other causes are looked for, the fewer cases due to dentition only, even in these susceptible infants, will be found. Rarely, a case calling for lancing the gums will be discovered.

The second or permanent teeth are cut as follows : 1 . First four molars, at six years ; 2. Eight incisors, at seven to eight years ; 3. Eight tricuspids, at nine to ten years ; 4. Four canines, at twelve to fourteen years ; 5. Second four molars, at twelve to fifteen years ; 6. Third four molars at seventeen to twenty-five years. Except for the first four molars the order is about the same as for the first set. In growing, the second set cause atrophy of the roots of the first set until they loosen and fall out

X7BINE.

For obvious reasons accurate results as to quantity of urine in infancy are hard to obtain. During the first few days of

28 NORMAL DEVELOPMENT OF THE INFANT,

life the daily quantity is three ounces; by two months it increases to eight to ten ounces ; by six months to ten to sixteen ounces ; by two years to twenty ounces ; by five years to twenty-six ounces ; by eight years to forty ounces ; and by fourteen years to forty-eight ounces. The sj>ecific gravity averages from 1005 to 1010. The reaction is acid. Traces of albumin or of sugar may be found during certain periods, but rapidly disappear.

THE FiEGES.

These partake of the characteristics of meccyiiium for four or five days, when they change to mUk-^tooh. These are yellow, of the consistence of semi-solid butter, smooth, of acid reaction, and inodorous. The gases present are hydrogen and carbonic acid. The faeces amount to about three ounces per day in quantity, and are passed from two to four times daily. Chemically they consist of 85 per cent, of water, and of fat, proteids, lactic acid, salts, and bile-elements. Bacteria are present in large variety, especially the bacillus coli communis. Stools resulting from cows' milk are whiter, from the presence of more curds. When the child begins a mixed diet the stools assume the adult type.

SPECIAL SENSES.

Sight : This is present from birth, but the eyes are verj^ sensitive to light, and not till the fourth month do they seem to be used voluntarily.

Hearing : Deafness is present for a day or two. This is probably due to the absence of air from the tympanum, but when respiration is well established the hearing begins, and later becomes quite shaq). The infant does not seem to locate sounds before the fourth month.

Tonch : Sensation is present, but is dull for three months. It is highly developed m the tongue and lips, where the temperature-sense is also acute.

SPECIAL SENSES. 29

Taste : This sense is highly developed from birth.

Smell : We know scarcely anything about this sense.

Speech : This function is very variable in its development. Very much depends on efforts at training, as institution-children always talk much later than those brought up at home. By the end of the first year the child should begin to say a few words, and by the end of the second year should form a few sentences. If there has been no effort at speaking by the end of two years, probably some mental defect is present or " deaf-mutism " may be suspected.

Chapter III. Examination Of The Child

History : First obtain a careful account of the family history, and then the personal history of the child. Tlien gather together systematically all the facts about the present illness, willingly listening to all the ideas and observations of the mother or nurse about the child. Always inquire about the food and as to any drugs which may have been taken.

Inspection: A careful observation of the child is next necessary, trying to disturb it as little as possible. Notice the po^UioUf whether it is natural and easy ; the character of the sleep; the respiraJtion ; the skiuy its color and whether dry or moist; the facial expression; the nostrils, whether quiet or moving ; the cough, and if present its character ; the cry; the mental condition; the mouth, whether it is kept open or closed in breathing ; the condition of the eyes and pupils ; the presence or absence of enlarged lymph-glands ; the presence or absence of muscular movements or tmtchings; the presence of any discharges. Compare any of tlicse as found with the condition in a normal infant.

Physical Examination : First take the temperature^ by rectum if possible, as it is very hard to get by mouth, and the axillary temperature is uncertain. Then take the pulse, usually at the same time, remembering the comparative unimportance of its rate. Next strip the child, and examine the shin cjirofully for nishes. Auscultate and [H^rcuss the hairt and hcngs carefully. Palpate the abdomen, remembering that normally the liver reaches below the free border of the ribs, and that the spleen cannot be felt. Inspect the genitals. Examine the muscular development. Examine the hones, then the extremities and the ribs. Investigate* the development of the nervous system, ^nA the functions dependent on it. Examine the fontanelle, and if open see if it is bulging, flat, or depressed. Lastly examine minutely the cars, the mouth, and the throat.

Chapter IV. Diseases Of The New-born Infant

ASPHYXIA.

Fonns: There are two distinct forms of asphyxia after birth — (1) the congestive, and (2) the anaemic. In the first, the child is livid in color, appears swollen, and has good muscular tone and a full, strong pulse. In .the second form the skin is pale, the muscles flaccid, and the pulse inappreciable.

Prognosis : The prognosis in the congestive variety is far better than in the anaemic.

Asphyzia — ^treatment : This is simple in the fcnrmer ; first allowing a little blood to escape from the cut cord to reduce the internal congestion, and then alternately dipping the baby into hot (110° F.) and cold water. The reflexes being still present, the response is marked.

In the latter variety allow the child to get as much blood as possible from the placenta, and then jxjrform artificial respiration, for a verj' long time if necessary, at the rate of ten to fifteen times per minute. Sylvester's method is undoubtedly the best, as the baby can be kept in a tub of hot water during the manipulations. Be sure that the mouth and pharynx are clear of any foreign substance.

In some cases where artificial respiration fails, direct infla^ fion of the lungs, by the mouth-to-mouth method, or by passing a catheter into the lar}Mix, succeeds. In these cases, after rt»8pi ration is established attention is necessary for some time to prevent relapses and to be sure that atelectasis is overcome.

ICTERUS.

This common aflfection, of still unknown origin, appears from the second to the fifth day and lasts about a week. It occurs in about one-third of new-born infants. It is probably hepatogenous in origin, and due to resorption of bile-pigment. It requires no treatment^ disapjxjaring easily.

In some cases an early jaundice increases in intensity and presents constitutional symptoms. In these cases the prognosis is bad, and there is usually either a septic infection from the umbilical vessels or a congenital malformation of the bile-ducts.

OPHTHALMIA.

Definition : This is an infectious conjunctivitis y in the majority of the cases due to the gonococcu s. less frequently to the ordinary pyogenic germs. AH grade s, from a mijd. Ci0j4iinctivitis _to chemosis, corneal ulceration, and sloughing, -may occur.

Ssrmptoms: Redness, swollen lids, copious purulent discharge, pain, and photophobia.

Ophthalmia — ^treatment : Propjiyl^ x^^j ^ already described, is most important. If the disease is started, frequent and thorough cleansing with a saturated boric acid solution, or a 1 : 5000 bichloride of mercurj^ solution, is necessary. Twice a day a few drops of a 1 per cent, silver nitrate solution should be instilled in the eyes, and in the intervals ice-cold compresses, frequently changed, should be kept on the lids. It 18 always wise to call in the services of an oculist.

CEREBRAL HEMORRHAGE.

Source : A quite frequent accompaniment of birth is some form of bleeding in the skull, which is regularly from the congested vessels of the pia maier. These hemorrhages are mostly mechanical, and are seen in prolonged non-instrumental births quite as frequently as after the use of forceps. The hemorrhage is situated usually on the base, and nearer the back than the front of the brain. Thev oc(;ur in both breech and vertex cases.

Oerebral hemorrhage — sjrmptoms: If large, the baby is often stillborn. If smaller, asphyxia, torpor, irregular resj)iration, feeble, slow pulse, and convulsions are the regular symptoms. The pupils are variable, but oscillatory move-

CEPHALHJEMATOMA— OBSTETRICAL PAltALYSES. 33

ments of the eyeballs are frequent. According to the size and location of the clot, localized paralysis or complete hemiplegia is present. In the surviving cases permanent damage to the brain and its supplied parts is left, the symptoms depending on the location of the lesion, such as idiocy, epilepsy, monoplegia, diplegia, or hemiplegia.

Cerebral hemorrhage — treatment: This is almost entirely preventive by shortening long labors by the judicious use of the forceps. For the changes left behind by these accidents very little can be done.

OEPHALSLSMATOMA.

Definition : This is an extravasation of blood under the pericranium, and due to some traumatism during labor. The tumor is always limited by the attachment of the pericranium, nev er pas sing over a suture or fontancUe. It appears from the first to the fourth day, and grows gradually for about a week, when it slowly disappears. It is fluctuating, and shows none of the signs of inflammation. As it grows older there is a raised ridge around the margin due to organization of the eflFused blood, and giving the impression of a depression of the skull inside this ridge. If the scalp is lacerated, infection is likely to occur, followed by abscess. The whole tumor will disappear in two or three months by a process of absorption, unless some accident happens to it.

GephalliaBmatoma — ^treatment : Care should be exercised to protect the part from injury, and to keep aseptic any abrasions of the skin in the neighborhood. Non-interference is otherwise the proper course. If an abscess forms, open and pack.

OBSTETRICAL PARALYSES.

The two commonest forms of this condition are (1) facial, and (2) brachial, paralysis. The fo/'mer (1) is due to pressure on the facial nerve by one of the blades of the forceps. The eye on the paralyzed side remains oj)en, and in moving the mce this side is found to be smooth, and the mouth is drawn to the sound side.

34 D^EASES OF THE NEW-BOHN INFANT.

Facial paralysis — treatment : None is needed, as the condition usually diiiap|>e£yrswU In those cases where no improvement appears within a month regular electrical treatment should be given.

In (2) brachial, also called Erb's^^paxid^sis one or more groups of muscles of the upper extremity are paralyzed. Here also the cause is usually traumatism from the forceps or from pulling on the arm, or in the axilla. The muscles most often aiFected are the deltoid^ biceps, brachialis anti cus, supi - na tor Ipngus, and the supra- an(f infm-spinatus. The arm hangs flaccid, and after some time the muscles atrophy.

Brachial paralysis — ^treatment: Most of these cases also recover spontaneously in a few months, but this can be has - tened b y electrical treatment. Strychnine is a useful drug in both forms. '